626 Sparks Rd (2) ,-- -,., DAVIE COUNTY ENVIRONMENTAL HEALTH
P.O.Box 848/210 Hospital Street
. Mocksville,NC 27028
(336)753-6780/Fax#(336)753-1680
OPERATION PERMIT
�ccc�u�t �: 990005826 'T�x F'I�€i�H#: B60000002506
�iiled To: Achan Smith .. . : Su�adi�i�iaii lnf�: . . .
Refer�r�ce Na��e.: . , : ::LacationlAddr�s�: 626 A Sparks Road-27028 ; . � . �
F�ro�c�sec9 F�cility: Residence . : I��o�er�y�Siz�: 5 Acres ,
�,T�*'��*T'h���uance of this Operation Permit shall iridicate the system described on the ATC has been`installed
in compliance with Article 11 of G.S.Chapter 130A,Section.1900"Sewage Treatment and Disposal Systems,"
but shall in NO WAY be taken as a guarantee that the system will function satisfactorily for any given period of
time.
' System Type:�S.T.Manufacturer��;� Tank Date �—? Tank Size 10C�D
Pump Tank Size /
System Installed By: C�' �Qb' v�. E.H.Specialist: � ate: D�
GPS Coordinate:
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DCHD 11/06(Revised)
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DAVIE COUNTY ENVIRONMENTAL HEALTH •
P.O.Box 848/210 Hospital Street
Mocksville,NC 27028 _
(336)753-6780/Fax#(336)753-1680
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
. �c�t�u�t #: 990005826 T�x PiNi�H#; B60000002506
Billcd To: Achan Smith ... :Sufadivisiort Infc�: .
R�fer�rtce Nanie: . .. . '. LocatioNAd�r��s: 626 A Sparks Road-27028 _
� Pro�ased Facifify: Residence : . . . �: P�oper#y Size: 5 Acres .. .
Site Type: f,�New ❑Repair ❑Expansion
t�TC Nurnber: 5885 . . . . ..
**NOTE**This Authorization to Construct(ATC)MUST BE ISSUED by the Davie County Environmental
Health Section prior to issuance of any building permit(s),(in compliance with Article 11 of G.S.Chapter 130A
Wastewater Systems,Section.1900 Sewage Treatrnent and Disposal Systems). THIS AUTHORIZATION TO
CONSTRUCT IS VALID FOR A PERIOD OF FIVE YEARS. This ATC is subject to revocation if site plans,plat �
or the intended use change.
Residential Specifications: #Bedrooms #Bathrooms #People Basement❑Basement plumbing❑
Non-Residential Specifieations: Facility Typ S� #People #Seats
_Square Footage(or Dimens ons of Facility)
Lot Size��_ Type of Water Supply: ❑County/City 0 Well ❑Community Well
System Specif cations: Design Wastewater Flow(GPD),�� Tank Sizel�d GAL.Fump Tank�GAL.
Trench Width�� Max.Trench Depth�(��` Rock Depth�/A Linear Ft.
Site Modifications/Conditions/Other: -
Contact the Davie County Environmental Health Section for final inspection of this system between
8:30—9:30a.m.on the da of installation. Tele hone# 336 751-8760.
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Environmental Health Specialis Date: 2��
DCHD 1 I/06(Revised) '
� � � DAVIE COUNTY ENVIRONMENTAL HEALTH
P.O.Box 848/210 Hospital Street
Mocksville,NC 27028 .
(336)753-6780/Fax#(336)753-1680
AUTI30RIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
Accc�unt #: 990005826 T�x P1N:EH#: 660000002506
BiEI��To: Achan Smith .,., ;Sufa�ivis�ort Info: :. .
R�fer�r�ce �l���e: . _ _. :- .LucatianlAddr�ss: 626 A Sparks Road-27028 � ., : :;: .
Propas�c� Fa�;i€ity: Residence :- :,:,.•� - ` � � , �:�, P�o�erty Size: 5 Acres _ � : , : : :
Site Type: f,�New. ❑Repair ❑Expansion
��T'C Nurnber: 5885 . . ... , . , �
**NOTE**This Authorization to Construct(ATC)MUST BE ISSUED by the Davie County Environmental
Health Section prior to issuance of any building permit(s),(in compliance with Article 11 of G.S.Chapter 130A
Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems). THIS AUTHORIZATION TO
CONSTRUCT IS VALID FOR A PERIOD OF FIVE YEARS. This ATC is subject to revocation if site plans,plat
or the intended use change.
Residential Specifications: #Bedrooms #Bathrooms #People Basement❑Basement plumbing❑
Non-Residential Specifications: Facility Typ s� #People #Seats
.Square Footage(or Dimens ons of Facility)
Lot Size �Q�( Type of Water Supply: ❑County/City ❑Well ❑Community Well
System Specifications: Design Wastewater Flow(GPD)l�Tank Size��GAL.Pump Tank�GAL.
Trench Width�� Max.Trench Depth�(��� Rock Depth /(,/� Linear Ft.
Site Modifications/Conditions/Other: -
Contact the Davie County Environmental Health Section for final inspection of this system between
8:30—9:30a.m.on the da of installation. Tele hone# 336 751-8760.
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Environmental Health Specialis Date: 20�
DCHD 11/06(Revised) �
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• • Davie County Environmental Health
P.O.Box 848/210 Hospital Street
Mocksville,NC 27028
(336)753-6780/Fax(336)753-1680
IMPROVEMENT PERMIT
Account #: 990005826 � Tax PIN/EH#: 660000002506
Billed To: Achan Smith Subdivision Info:
Address: 626 Sparks Road Location/Address: 626 A Sparks Road-27028
City: Mocksville Property Size: 5 Acres
Reference Name:
Propq��.��t�������c�ment Permit DOES NOT authorize the construction of a wastewater system. An
Authorization To Construct a wastewater system must be obtained from this office prior to the
construction/installation of a wastewater system or the issuance of a building permit(in compliance with
Article 11 of G.S. Chapter 130A,Wastewater Systems). This Improvement Permit is subject to
.� � revocation if site plans,plat or the intended use change.
Permit Type: �New ORepair OExpansion Permit Valid for: tj15 Years �❑No Expiration �
Residential Specifications: #Bedrooms #Bathrooms #People Basement❑ Basement plumbing0
Non-Residential Specifications: Facility Type ` �h� #People�#Seats
� Square Footage(or Dimensions of Facility)
Design Flow(GPD): �� Type of Water Supply: �County/City �Q,Well ❑Community Well
Site Modifications/Permit Conditions:
S stem T e LTAR
Initial S°p `
Re air 4
.Site Plan .
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Environmental Health Specialist • Date� 2C�1 Z
i.p.l 1-06, . . .
Feb 2B 12 09:15a irlortnation Services 3387531880 p��
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.. . . �, • '
ApPLICATION�OR SIT�EVALUATION/IMPROVEMENT PERMIT&ATC
, ' Datiic Coanty Enviconmcntal Hcatth �����
P.O.Box 848/2I0 IIospital Stecet �
Mocksvillc,NG 27028 7
. (33�753-6780/Fax(336)753-1680 � F�e � n z41z
b`�
npplication For. O Si�c f:valuationllrnprovcmrnt Pamit U Authorizacion To Construc4(rlTC) �.Bolh
-• T�pe ofApplicaeion; L�Trew System ❑Repair to Facisting Systcm Uf;xpansion/Mexlifieation of�xini�g System or Faci�tyr�
••'IMPORT�tN7'"*THIS APPL1CA770N G�VNOT BEPRUCESSED tINLB$$A�.L OF Tt�ILEQUIRED
lYFO1tMAT10N iS PR�Vi17ED. Refer to the INFnRMATION F�ULLfffM for iastcucti�s.
. A1'PLfCANT INFOItMAT10T
Nflme L�� J�Y�1 Contact Pexson ��.�'►1 JYY11�
Address E�s' 3 av 5 Home Phone �320 9 LI'� ,�,�(�(_
CitylStatclG(P o� �i -� l3u�incss Phone __,.
Name on PennidATC ifD�e�cnl U�an Above
MaiGng Add�ss __ City/5tateJZin___ : ,�
. .� _.
PROz'ERTY INFORMATION 'Datc ElousdF'acilitv Comera FI.� ed
NOTC� A survcy plat or a�le plan musc accompany chis application. lncluded:fl Slcc�'inn 0 Plat(to scak)
(P�r►it is v lid or 60 m ndts 'th site pinn;no cxpirarion widi coulplete plat_) ��
� Owner's Namc �fl�� ph�ne Nu bc;r ��� �
Owncr's Address Ciry/StauJZip � �� G _ "La2. (
PcopartyAddress o 5 City • Q�b����r/
Lot Size S n C h 5 7:tx PIN# .1/
Subdivision Npme(iFa licable) Section/LotM
DireCtions To Site: �g 1►.ir O QO�� —�f)1n ��M�-
R oh $ r w ,• af„
If the enswet t xny of the followingquestiona ia�`Yes",sugpprttng cumcntwtion must bc attachod: ��
An ihae arry cxistitu;wa�tewate�systems on the sitcY xYes No
Does the si�c connin jurisdi�tional wetlaads? Yes�No ,
Am thac any eascments or righ�-of-wqys'on the site7 Ycs No
is the sitc subjxt to xpproval by another public agcncy? _Ycs�4 No
W iU wasttwaccr oflxc thati domestie sewagc be geaczated? _Ya�QNo
IF R�.SIDENC�FIL!OUT THE ROX BEbOW
�Pcoplc fi Bedrooms �! #Bathtoouu Gatden Tub�'Whiripool f1Ycs �No�
8a.aement:OYes?�No 8asementPlumbing: I lYcs �ri10 _J
IP NON-ItESiDEIVCF.FIL OUT THE BOX BELOW �
Type of FaeilityBusirtess �b Tota1 Squace Poo'tagc of Buildin� #People
*Sinlcs�,� tf Commodes it Showrrs� �, /.�Urinnls���
Estimated Water Usage(gallons per dny)_ �� _(Attach documontation of similar faeiliry water consumption)
FQODSERV]CE ONLY: #Seats
Type systrm rcquested; JComentional'�Accepted 0[nnovetive pAlurnative- �qher
• •-- --..._... . . . .. .. . .. . ` �
•s
�Vater Supply Type;Cl CounryrCi�v Watcr Cl Ncw Wcll �.xiSCng Well f]Communily Well
D�you antieipa�eddilio�s or exn�naians af thv fWCilily thi�sysum is intendod to arnc?l�Yes i�Nu
Tf yes,wlvU typc? , _ ,
'Chis ig to eertify that ih�infotmation provided ort lhis application is true ond currcct to lht best of my krtowloclbc. I undttsLmd
ilult uny perTnit(s)Or ATC(5)issucd hcrrzfter ue Subject t0 SuSp�:rlsion or rcvoCation if thC SitC is tdtaal,Uie intended use
changes,or if the informaiion sub�aiued in this appl;raticm ix CalsiGnd or changed C htrcby�rant right of entry to du Authori2nd
ReprcccnWtive of the O:vie County Hcalth[kpariment to conduct neeess3ry inspecGons ta detennine comptiance with applicabin
laws tules. T undasL tlut 1 tm respomibla for thc proper ideatiGwtion und L►belins af pcopccry lin�and conters nnd
lxa n a d�le ' or in thc houu•lfaciliry location,propoxd wcll location aad the loeatioa oFuny other amenities. �
L'
' .Stf�',[�Ylilt C�IM�'.0
Properiy o ur's or owner's te al cept��ative�ibmature pate(s):
�'�.�'�2, Clicnt Notification llute
yate E��
Sign given UYcc:1No Accounl K J�� _ I
Revised U/Ob Invoicei� �-��
GoMAPS - Davie County NC Public Access .
� � � �';"I WATERSHED STRUCTURES
, � , f� {
�� � ; WATER BOD�ES • �
S __. �: +
; � � COUNTY_BOUNDARY _
;i' �� A ADDRESS �
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� ;;' 1 y,� �� DRfVES �
� �
}` -- � STREETS
�� � � tk.''' RAILROAD CENTERLINE
, • ,;' � � i.� -
, S ti a PARCELS
�
�G�t�� , �1 CITY_LIMITS
f �+ BERhfUDA RUN
�`Y� � � COOLEEM1tEE
1
r � � onviE couNrr
f'] ` ~} 1 � h10CKSVILLE
V r 1 ���
� 1 nccounties
� � DAVIE
� � <all other values>
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***WARNING:THIS IS NOT A SURVEY!*** Wednesday,February 29 2012
This map is prepared for the inventory of real property found within this jurisdiction,and is compiled from recorded
deeds,plats,and other public records and data.Users of this map are hereby notified that the aforementioned public
primary information sources should be consulted for verification of the information contained on this map.The
County and mapping company assume no legal responsibility for the information contained on this map.
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, , , , DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
APPLICANT INFORMATION PROPERTY INFORMATION
Account #: 990005826 Tax PIN/EH#: 660000002506
Bilied To: Achan Smith Subdivision Info: ,
Reference Name: Location/Address: 626 A Sparks Road-27028
Proposed Facility: Residence Property Size: 5 Acres Date Evaluated:
Water Supply: On-Site Well 1� Community Public
Evaluation By: Auger Boring /� Pit Cut
FACTORS 1 2 3 4 5 6 7
Landsca e sition (.. L
Slo % C9 °
HORIZON I DEPTH � _ p
Texture rou
Consistence
Structure �
Mineralo . � ( � •
HORIZON II DEPTH -
Texture rou - - -
Consistence F
Structure -►uQk
Mineralo �: l ,
HORIZON III DEPTH
Texture rou
Consistence
Structure �
Mineralo �
HORIZON IV DEP'TH
Texture rou
Consistence
Structure
Mineralo -
SOIL WETNESS
RESTRIGTIVE HORIZON
SAPROLITE
CLASSIFTCATION
LONG-TERM ACCEPTANCE RATE
SITE CLASSIFICATION: �S . EVALUATION BY: �G �
LONG-TERM ACCEPTANCE RATE: -��_ OTHER(S)PRESENT: � L
REMARKS: a ►`�-� I'��
LEGEND
Landscane Position
R-Ridge S -Shoulder L-Lineaz slope FS-Foot slope N-Nose slope
CC-Concave slope CV-Convex slope T-Terrace FP-F1ood plain H=Head slope
�g �
S-Sand LS-Loamy sand SL-Sandy loam L-Loam SI-Silt
SICL-Silty clay loam SIL-Silty loam - CL-Clay loam SCL-Sandy clay loam
SC-Sandy clay SIC-Silty clay C-Clay
CONSIST .N .
MMQISL ,
VFR-Very friable FR-Friable FI-Firm VFI-Very fum EFI-Extremely firm
�
� NS-Non sticky SS-Slightly sticky S-Sticky VS-Very Sticky
NP-Non plastic SP-Slightly plastic P-Plastic VP-Very plastic
�
SC-Single grain M-Massive CR-Crumb GR-Granular ABK-Angular blocky
SBK-Subangulaz blocky PL-Platy PR-Prismatic . •
Mineralogv �
1:1,2:1,Mixed
LiQt� ,
Horizon depth-In inches
Depth of fill-In inches
Restrictive horizon-Thickness and inches from land surface
Saprolite-S(suitable),U(unsuitable)
Soil wetness-Inches from land surface to free water or inches from land surface to soil colors with chroma 2 or less
Classification-S(suitable),PS(provisionally suitable),U(unsuitable)
LTAR/-Long-term acceptance rate-gaUday/ft2 �� . DCHD OS/OS(Revised)
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